CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

Out-of-network pharmacy prescription coverage and reimbursement

This document explains when Blue Cross Blue Shield - South Carolina may cover prescriptions filled at out-of-network pharmacies, limits on such coverage, and how members can request reimbursement. It affects plan members who obtain prescriptions outside the network or service area.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyOut-of-network pharmacy prescription coverage and reimbursement

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionMembers who use an out-of-network pharmacy should pay up front and submit a paper claim with receipt to OptumRx to request reimbursement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

10Max out-of-network fills per year

1-888-645-6025Customer Service

8a–8p ETCustomer Service hours

Out-of-Network Pharmacy Coverage Criteria

Coverage criteria for out-of-network pharmacy fills

Out-of-network pharmacy fills may be covered or reimbursed only in specific situations and are subject to limits and member responsibilities.

Covered when prescriptions are related to care for a medical emergency or urgently needed care.

Covered when member is traveling or away from the plan's service area and cannot access a network pharmacy; member should call Customer Service at 1-888-645-6025 (TTY: 711) to locate network pharmacies when possible.

Covered when no network pharmacy within a reasonable driving distance provides 24-hour service and member cannot obtain timely access.

Covered when the covered drug is not regularly stocked at network retail or mail-order pharmacies (includes orphan or other specialty drugs).

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyOut-of-network pharmacy prescription coverage and reimbursement

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionMembers who use an out-of-network pharmacy should pay up front and submit a paper claim with receipt to OptumRx to request reimbursement.

SourceLink

On This Page

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Provider / Member Actions and Requirements

Documentation Required

Out-of-Network Pharmacy Coverage — Provider / Member Actions

Out-of-network pharmacy coverage is available only in specific situations. Providers must document the circumstance (medical emergency, urgent need while traveling, lack of a reasonably accessible network pharmacy, medication not stocked by network pharmacies, or drugs dispensed by an out-of-network institutional pharmacy during an outpatient encounter) when submitting claims or advising members. Members may be instructed to seek reimbursement if they pay out-of-pocket; check member benefit details and direct members to Customer Service for help locating a network pharmacy. No prior authorization is required specifically for out-of-network fills under these circumstances, but standard medical necessity and coverage rules still apply.

Covered when related to a medical emergency or urgently needed care
Covered when member is traveling or away from the plan's service area — advise member to check supply before travel and consider mail-order or extended supply
Covered when no network pharmacy is available within a reasonable driving distance providing timely/24-hour service
Covered when the covered drug is not regularly stocked at network retail or mail-order pharmacies (e.g., orphan or specialty drugs)
Covered when dispensed by an out-of-network institution-based pharmacy during an ER, provider-based clinic, outpatient surgery clinic, or other outpatient setting
Members who pay out-of-pocket may need to follow the plan's reimbursement process — direct them to Customer Service (1-888-645-6025, TTY 711) for assistance and to locate network pharmacies

Definitions

Out-of-network pharmacy

DefinitionA pharmacy that is outside the plan's network or service area where a member obtains a prescription

Typical examplesRetail pharmacies not contracted with the plan, mail-order providers outside the network, and institution-based pharmacies when not in-network

Implication for membersPrescriptions filled at an out-of-network pharmacy are generally not covered except in defined circumstances; member may pay up front and submit for reimbursement

Covered situations

Medical emergency or urgently needed careCovered when prescriptions are related to care for a medical emergency or urgently needed care

Travel or away from service areaCovered when member is traveling or away from the plan's service area and cannot access a network pharmacy; contact Customer Service for local network options

No nearby 24-hour network pharmacyCovered when no network pharmacy within a reasonable driving distance provides 24-hour service and timely access is not possible

Drug not regularly stockedCovered when the covered drug is not regularly stocked at network retail or mail-order pharmacies (includes orphan or specialty drugs)

Institution-based outpatient dispensingCovered when member receives a covered prescription from an out-of-network, institution-based pharmacy while a patient in an ER, provider-based clinic, outpatient surgery clinic or other outpatient setting

OpenPayer

Out-of-network pharmacy prescription coverage and reimbursement

Out-of-Network Pharmacy Coverage Criteria

Coding and Limits

Provider / Member Actions and Requirements

Definitions